Rationale Long term treatment of chronic urticaria (CU) often requires oral steroids and/or sedating H 1 antihistaminics (H 1), although these are associated with unacceptable side effects. We evaluated the use of steroid-sparing agents as alternatives. Methods 40 patients, aged 4 to 85; 11 male, 29 female, with CU on daily or “burst” oral prednisone were studied. Each patient underwent a complete H&P, when possible, routine allergy skin testing to aeroallergens, foods and autologous skin testing (ASST) for self reactivity. All patients were started on non-sedating H 1. Those who failed were offered cyclosporine or dapsone. Results Ten patients could not be skin tested; 23 had positive reactions to aeroallergens or foods; however, avoidance did not control their CU; and 24/30 had a positive ASST. 12 of the 40 patients responded to high dose non-sedating H 1. Seventeen patients received dapsone; 7 responded well; 1 developed profound anemia; and 1 patient self-discontinued dapsone. Twenty-three patients were started on cyclosporine; 16 responded dramatically; 4 responded modestly, using only non-sedating H 1; 3 did not respond. Patients with positive skin test for aeroallergens or foods (23/40) and/or a positive ASST (24/40) had the highest cyclosporine success rate. Discussion Our data demonstrates that most patients with CU can be controlled without the use of oral steroids. If high dose non-sedating H 1 fail, then immunomodulating drugs in particular cyclosporine (for patient with a positive skin test) or dapsone appear to be very effective. Using this approach we demonstrated a success rate of 92.5% in eliminating oral prednisone in the treatment of chronic urticaria.